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CITY OF PASADENA COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) (City of Pasadena, Texas)

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BROWSE CITY OF PASADENA, TEXAS (TX) FORMS

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Jeff Wagner, Mayor
CITY OF PASADENA
COMMUNITY DEVELOPMENT BLOCK GRANT
(CDBG)
APPLICATION
Applications Due: Thursday, April 2, 2020 at 4:00 p.m. CST
NO LATE APPLICATIONS WILL BE ACCEPTED
Applications may be either mailed or hand delivered to:
Office of the City Secretary
1149 Ellsworth Drive, 2
nd
Floor
Pasadena, Texas 77506
Any application received after the above stated date and time will be returned unopened.
Your application will not be evaluated if all the submission requirements are not met and
the documentation is not attached.
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I. Contents
I. TERMS AND CONDITIONS 3
II. APPLICATION INSTRUCTIONS 7
III. OTHER REQUIREMENTS 8
IV. EVALUATION CRITERIA 9
V. SAMPLE EVALUATION FORM 10
VI. APPLICATION FOR FUNDING 13
VII. SUBMISSION CHECKLIST 30
VIII. APPLICATION SUBMISSION LABEL 31
IX. CONFLICT OF INTEREST 32
X. INDEMNITY CLAUSE 33
XI. NON-COLLUSION AFFIDAVIT (MUST BE NOTARIZED) 34
XII. CERTIFICATE OF NON-DEBARMENT (MUST BE NOTARIZED) 35
XIII. SOLICITATION QUESTIONNAIRE 36
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I. Terms and Conditions
This application does not commit the City of Pasadena (City) to award a contract or to pay any costs incurred as a
result of preparing such a response. The City reserves the right to accept or reject any and all applications received
in response to this request, to negotiate with all qualified applicants or to cancel in part, or in its entirety, this
application if it is in the best interest of the City. The City may choose to proceed with any or all portions of this
application at its sole discretion. These instructions are standard for all contracts for commodities or services issued
through the City. General Requirements apply to all advertised bids/proposals/applications; however, these may be
superseded, whole or in part, by the SPECIAL CONDITIONS OR OTHER DATA CONTAINED HEREIN.
READ THIS ENTIRE DOCUMENT CAREFULLY. FOLLOW ALL INSTRUCTIONS. YOU ARE RESPONSIBLE FOR
FULFILLING ALL REQUIREMENTS AND SPECIFICATIONS. BE SURE YOU UNDERSTAND THEM.
1. CHANGES IN SCOPE OF WORK
The City may request changes in the scope of work to be performed. Such changes, including increase or
decrease in compensation must be mutually agreed upon and incorporated by written amendment to the
agreement.
2. ANTI-LOBBYING PROVISION
During the period between the publication date and the contract award, applicants, including their agents and
representatives, shall not directly discuss or promote their application with any member of the Pasadena City
Council, Community Development Advisory Board or City Staff except in the course of city-sponsored inquiries,
briefings, interviews or presentation, unless requested by the City. This provision is not meant to preclude
respondents from discussing other matters with City Council members, Community Development Advisory
Board members or City Staff. This policy is intended to create a level playing field for all potential applicants,
assure that contract decisions are made in public and to protect the integrity of the application process.
Violation of this provision may result in rejection of the applicant’s application.
3. POTENTIAL CONFLICTS OF INTEREST
An outside consultant or contractor is prohibited from submitting an application for services on a City of
Pasadena project of which the consultant or contractor was a designer or other previous contributor, or was
an affiliate, subsidiary, joint venture or was in any other manner associated by ownership to any party that
was a designer or other previous contributor. If such a consultant or contractor submits a prohibited
application, that application shall be disqualified on the basis of conflict of interest, no matter when the conflict
is discovered by the City.
4. APPLICABLE LAW AND VENUE
Any agreement resulting from this application shall be construed according to the laws of the State of Texas.
The City and Agency’s agree that the venue for any legal action under this agreement shall be the Harris County,
Texas. In the event that any action is brought under any agreement resulting from the application in Federal
Court, the venue for such action shall be in the Federal Judicial District of Harris County, Texas.
5. IMMIGRATION REFORM and CONTROL ACT (IRCA)
The Immigration Reform and Control Act (IRCA), also Simpson-Mazzoli Act (Pub.L. 99-603, 100 Stat. 3359,
signed by President Ronald Reagan on November 6, 1986) is an Act of Congress which reformed United States
immigration law. The Act made it illegal to knowingly hire or recruit illegal immigrants (immigrants who do
not possess lawful work authorization), required employers to attest to their employees' immigration status,
and granted amnesty to certain illegal immigrants who entered the United States before January 1, 1982 and
had resided there continuously. The Act also granted a path towards legalization to certain agricultural
seasonal workers and immigrants who had been continuously and illegally present in the United States since
January 1, 1982.
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6. APPLICATION FORM COMPLETION
Unless otherwise specified, respondents must use the application form provided. Forms shall be completed
and submitted to the City Secretary’s Office. The contract will be binding only when signed by the City of
Pasadena, funds are certified by the City Controller, as applicable, and a Purchase Order issued.
7. SCANNED OR RE-TYPED RESPONSE
If in its application response, applicant either electronically scans, re-types, or in some way reproduces the
City’s published application, then in event of any conflict between the terms and provisions of the City’s
published application, or any portion thereof, and the terms and provisions of the application response made
by, the City’s specifications as published shall control. Furthermore, if an alteration of any kind to the City’s
published specifications is only discovered after the contract is executed and is or is not being performed; the
contract is subject to immediate cancellation.
8. APPLICATION RETURNS including ALTERNATE APPLICATIONS
Applicants shall submit six (6) unbound copies with “ORIGINAL” signatures in a sealed envelope or package
of comparable size. Please cut out and affix the application Label found on the “Application Submission
Label” section to the outermost mailing envelope (UPS, USPS, FEDEX, etc.) of your application to ensure
proper delivery!
Applicants must return all applications to the following location by the date and time specified:
City of Pasadena
City Secretary’s Office
1149 Ellsworth Drive, 2
nd
Floor
Pasadena, Texas 77506
Late applications will not be accepted, and will be returned to applicant unopened.
9. AWARD OF CONTRACT
The City anticipates entering into a contract to be most advantageous to the City. The respondent understands
that this application does not constitute an agreement or a contract with the City. An official contract or
agreement is not binding until applications are reviewed and accepted by the City and a written agreement or
contract is approved by both the City and the successful applicant. The City Council must award the contract
and the Mayor, or other person authorized by the Mayor, must sign the contract before it becomes binding on
the City of Pasadena or the bidders. Department heads are NOT authorized to sign agreements for the City of
Pasadena.
10. PROTESTS
10.1. All protests regarding the solicitation process must be submitted in written form to the Community
Development Manager within five (5) working days following the submission of the application. This
includes all protests relating to legal advertisements, deadlines, application submittals, and all other
related procedures under the Local Government Code, as well as any protests relating to alleged
improprieties or ambiguities in the specifications contained herein or in the contract documents.
10.2. Post-award protests must be submitted in written form to the Community Development Manager
within five (5) working days after award and must specify the grounds upon which the protest is based.
A valid protest shall;
10.2.1. Come from an actual respondent for the contract, and
10.2.2. Who claim to be the rightful awardee. That is, the protest is not valid if filed by a respondent who
cannot show they would be awarded the contract if their protest were accepted.
10.3. The Community Development Manager, having authority to make the final determination, will respond
within ten (10) working days to each substantive issue raised in the protest. Allowances for
reconsiderations shall be made only if data becomes available that was not previously known, or if there
has been an error of law or regulation.
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11. INDEPENDENT CONTRACTOR
It is expressly understood and agreed by both parties hereto that the City is contracting with the successful
applicant as independent contractor/subrecipient. The parties hereto understand and agree that the City shall
not be liable for any claims which may be asserted by any third party occurring in connection with the services
to be performed by the successful applicant under this contract and that the successful applicant has no
authority to bind the City.
12. INSURANCE
If required, specific insurance provisions will be included in the application process. A copy of an insurance
certificate must be submitted within ten (10) days from the date of the request made by the Community
Development Department. The successful applicant will be required to maintain, at all times during
performance of the contract, the insurance detailed in bid/proposal specifications. Failure to provide this
document may result in disqualification of the application.
13. WAIVER OF SUBROGATION
Applicant and applicant’s insurance carrier waive any and all rights whatsoever with regard to subrogation
against the City as an indirect party to any suit arising out of personal or property damages resulting from
respondent’s performance under this agreement.
14. TERMINATION
The City reserves the right to terminate the contract for default if applicant breaches any of the terms therein,
including warranties of the applicant or if the applicant becomes insolvent or commits acts of bankruptcy.
Such right of termination is in addition to and not in lieu of any other remedies which the City may have in law
or equity. Default may be construed as, but not limited to, failure to deliver the proper goods and/or services
within the proper amount of time, and/or to properly perform any and all services required to the City’s
satisfaction and/or to meet all other obligations and requirements.
15. TERMINATION-NOTICE
Either party may cancel the contract at any time after award. The City shall be required to give the applicant
notice thirty (30) days prior to the date of cancellation of the contract. The applicant shall be required to give
the City written notice sixty (60) days prior to the date of cancellation of the contract. The City may terminate
the contract without cause upon thirty (30) days written notice.
16. INDEMNITY
CONTRACTOR/SUBRECIPIENT covenants and agrees to FULLY INDEMNIFY and HOLD HARMLESS, the
CITY and elected officials, employees, officers, directors, and representatives of the CITY, individually
or collectively, from and against any and all costs, claims, liens, damages losses, expenses, fees, fines,
penalties, proceedings, actions, demands, causes of action, liability and suits of any kind and nature,
including but not limited to, personal injury or death and property damage, made upon the CITY,
directly or indirectly arising out of resulting from or related to bid activities under this bid, including
any acts or omissions of CONTRACTOR/SUBRECIPIENT any agent, officer, director, representative,
employee, consultant or subcontractor of CONTRACTOR, and their respective officers, agents,
employees, directors and representatives while in the exercise or performance of the rights or duties
under this CONTRACT, all without, however, waiving any governmental immunity available to the CITY
under Texas Law and without waiving any defenses of the parties under Texas Law. The provisions of
this INDEMNIFICATION are solely for the benefit of the parties hereto and not intended to create or
grant any rights, contractual or otherwise, to any other person or entity. CONTRACTOR/SUBRECIPIENT
shall promptly advise the CITY in writing of any claim or demand against the CITY or
CONTRACTOR/SUBRECIPIENT known to CONTRACTOR/SUBRECIPIENT related to or arising out of
CONTRACTOR/SUBRECIPIENT’S activities under this CONTRACT and shall see to the investigation and
defense of such claim or demand at CONTRACTOR/SUBRECIPIENT’S cost. The CITY shall have the right,
at its option and at its own expense, to participate in such defense without relieving CONTRACTOR of
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any of its obligations under this paragraph. It is the EXPRESS INTENT of the parties to this contract, that
the INDEMNITY provided for in this section, is an INDEMNITY extended by
CONTRACTOR/SUBRECIPIENT to INDEMNIFY, PROTECT and HOLD HARMLESS the CITY from
consequences of the CITY’S OWN NEGLIGENCE, provided however, that the INDEMNITY provided for in
this section SHALL APPLY only when the NEGLIGENT ACT of the CITY is a CONTRIBUTORY CAUSE of the
resultant injury, death, or damage, and shall have no application when the negligent act of the CITY is
the sole cause of the resultant injury, death, or damage. CONTRACTOR/SUBRECIPIENT further AGREES
TO DEFEND, AT ITS OWN EXPENSE and ON BEHALF OF THE CITY AND IN THE NAME OF THE CITY, any
claim or litigation brought against the CITY and its elected officials, employees, officers, directors and
representatives, in connection with any such injury, death, or damage for which this INDEMNITY shall
apply, as set forth above.
16.1. PATENTS/COPYRIGHTS
The successful applicant agrees to indemnify and hold the City harmless from any claim involving
patent infringement or copyrights on goods supplied.
17. TAXES
The City is exempt from all federal excise, state and local taxes unless otherwise stated in this document. The
City claims exemption from all sales and/or use taxes under Texas Tax Code §151.309, as amended. Texas
Limited Sales Tax Exemption Certificates will be furnished upon written request to the City’s Purchasing
Department.
18. ASSIGNMENT
The successful applicant shall not sell, assign, transfer or convey this contract in whole or in part, without the
prior written consent of the City of Pasadena Community Development Department. Any such assignment or
transfer shall not release applicant from all contractual obligations.
19. CONTRACT RENEWALS
Renewals may be made ONLY by written agreement between the City and the applicant.
20. HOUSE BILL 914 DISCLOSURE OF CERTAIN RELATIONSHIPS
The Texas Ethics Commission adopted Form CIQ (Conflict of Interest Questionnaire) pursuant to H.B. 914.
Effective January 1, 2006, Chapter 176 of the Texas Local Government Code requires that any vendor or person
considering doing business with a local government entity disclose pertinent information in the Questionnaire
Form CIQ.
The questionnaire is to be filed in accordance with Chapter 176, Local Government Code by a person who has
a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the person
meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental entity not
later than the 7th business day after the date the person becomes aware of facts that require the statement to
be filed. See Section 176.006, Local Government Code. A person commits an offense if the person knowingly
violates Section 176.006, Local Government Code. An offense under this section is a Class C misdemeanor.
The CIQ Form can be located at http://www.ethics.state.tx.us/forms/CIQ.pdf
21. CERTIFICATE OF INTERESTED PARTIES
The Texas Ethics Commission adopted Form 1295 (Certificate of Interested Parties) pursuant to H.B. 1295.
Effective September 1, 2015, Chapter 2252 of the Texas Government Code requires that a business entity (any
vendor or person) doing business with a local government entity may not enter into a contract unless the
business entity has first submitted a completed Certificate of Interested Parties Form 1295 to the government
entity. The 1295 Form can be located at: https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm
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II. Application Instructions
The City receives a Community Development Block Grant (CDBG) annually from the U.S. Department of Housing and
Urban Development (HUD) to fund activities that primarily benefit low- to moderate-income (LMI) residents of
Pasadena. These funds are based on a formula for entitlement communities.
Each year the City uses a competitive application process to make a portion of the CDBG funds available for eligible
public service and non-public service activities. Eligible public service activities include, but are not limited to,
programs concerned with youth services and senior services, disability services, employment, crime prevention,
domestic violence victim services, legal services, drug abuse prevention, healthcare services, adult basic education,
etc. Eligible Non-Public Services activities include but are not limited to, acquisition and disposition of real property,
housing activities, public facilities & infrastructure, special economic development, and planning.
There is a statutory and regulatory limitation on the amount of CDBG funds which may be used for activities assisted
under the category of public services. The public services activity may not exceed 15% of the annual CDBG allocation.
CDBG Program
The CDBG program provides the City with the opportunity to develop viable communities by funding activities that
provide decent housing, suitable living environments and by expanding economic opportunities, principally for low-
to moderate-income persons.
CDBG National Objectives
For the purpose of this funding opportunity, federal legislation and regulations have established national objectives
that all CDBG funded activities must meet. The City must ensure that all activities meet one (1) of the three (3)
national objectives of the program. Each activity must:
1) Benefit people with low- to moderate-incomes (LMIs);
2) Aid in the prevention of slums and blight; or
3) Meet community development needs having a particular urgency.
Activities that do not meet one (1) of these three (3) broad national objectives are considered ineligible and cannot
be undertaken with CDBG funds.
Low- to Moderate Income Benefit: For an activity to meet this objective, it must either have income eligibility
requirements that limit benefits of the activity primarily to LMI persons, or the activity must be located in and serve
an area that is predominantly inhabited by LMI residents. (Refer to currently available census data for this
information).
Slums and Blight: For an activity to meet this objective, the activity must be designed to address and ameliorate the
conditions causing the slums and blight. The City determines which areas qualify under removal of slums and blight.
Urgent Community Development Needs: For an activity to meet this objective, the following criteria must be met: 1)
a situation must pose a serious and immediate threat to the health or welfare of the community; 2) it is of recent
origin or recently became urgent, and 3) it is unable to be corrected with other sources of funds.
It is imperative that applicants anticipate and plan for the methods that will be used to determine and
document the eligibility of the beneficiaries serve through the CDBG funded activity. Failure to adequately
document client data may result in neligibility of the activity, repayment of expended CDBG funds and
cancellation of any monies awarded.
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Ineligible Activities
Certain types of activities are considered ineligible for assistance through CDBG funds and include, but not limited
to the following:
Construction of, or improvements to, general government buildings and schools;
Routine operation, maintenance, and repair activities for public facilities; and
Assistance to churches or church-affiliated organizations unless a clear separation of purpose, mission, and
organizational relationship can be established between the church and the CDBG-funded activities.
III. Other Requirements:
Faith Based Agencies: Faith based agencies are eligible to apply. HUD issued a final rule amendment allowing faith-
based agencies to compete for CDBG funding on the same basis as other non-profits, however, CDBG funds cannot
be used to support worship or religious instruction. Religious activities must be offered separately from the CDBG
supported activity. Faith based agencies may not use direct CDBG funds to support inherently religious activities
such as worship or religious instruction. Faith based agencies that participate in the CDBG program shall not
discriminate against a program beneficiary on the basis of religion or religious belief. (Reference: CPD Notice 04-10)
Active Governing Body: Governance of the agency shall be vested in a responsible and active voluntary board,
which meets to establish and enforce policies. The Board shall be structured to be representative of the community
it serves.
Personnel: The agency must provide demonstration of adequate administration of the program to ensure delivery
of eligible services.
Non-Discrimination: Each agency receiving funds from the City is required to conduct its business in compliance
with the non-discrimination requirements of the City, State and Federal governments, as applicable. Equal
Opportunity in Employment policies are required.
DUNS umber: Each agency is required to have a DUNS (Data Universal Numbering System) number generated
from Dun & Bradstreet. If your agency does not have a DUNS number, one may be obtained free of charge for the
purpose of the application for federal funding. The website link to Dun & Bradstreet’s federal contract DUNS request
service is http://fedgov.dnb.com/webform. Regular business DUNS numbers require a fee.
WWW.SAM.GOV: The use of the DUNS (Data Universal Numbering System) number has been expanded to require
all applicant and grantee organizations to maintain an active registration in the System for Award Management
(SAM) Central Contractor Registry (CCR) database. The website link to the System for Award Management (SAM) is
SAM.GOV.
Accounting: Each agency shall maintain accounting records which are in accordance with Generally Accepted
Accounting Principles and auditing practices, as described in the Uniform Administrative Requirements, Cost
Principles and Audit Requirements for federal Awards (2 CFR 200). The final guidance at 2 CFR 200 supersedes and
streamlines requirements from OMB Circulars A-21, A-87, A-110, and A-122, Circulars A-89, A-102, A-133, and the
guidance in Circular A-50 on Single Audit Act follow-up. Agencies may be required to submit evidence of the
accounting systems to the City of Pasadena for approval prior to funds being awarded or disbursed.
Insurance: Once an agency’s project has been approved, at the time of contract signing, the agency must provide
evidence of insurance, including, but not limited to, multi-peril property and liability, medical, workers’
compensation, automobile liability, and other coverage as deemed necessary by the City Attorney, (with an
indemnification and hold harmless acceptable to the City of Pasadena). All certificates and endorsements are to be
received and approved by the City of Pasadena prior to commencement for the project.
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IV. Evaluation Criteria
Because the activities subject to funding by this application are specific in nature, the evaluation criteria must also
be specific to each activity type as outlined below. Minimum eligibility criteria for all applications are:
a. Nonprofit 501(c)(3) status for at least one (1) full year, or
b. Two (2) full years of operating experience under another non-profit entity, or
c. For-profit entity proposing to use funds for an eligible activity.
d. Demonstration of successful experience in undertaking comparable programs/projects.
e. Production and completion of projects previously awarded funds by the City of Pasadena.
*The form on the following page is a sample of evaluation criteria used for review and
scoring of applications. It is an example and should not be completed by your agency.
**Please note that applicants who have previously received CDBG funding from the City will also be
evaluated based on their past performance.
Past performance will include but not be limited to:
attainment of objectives in a timely manner
expenditure of funds at a reasonable rate
timely submission of client data reports
adherence to the Scope of Services
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V. SAMPLE EVALUATION FORM
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VI. APPLICATION FOR FUNDING
[THIS PAGE INTENTIONALLY LEFT BLANK]
NEXT PAGE IS PAGE ONE OF APPLICATION
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COVER SHEET
CDBG APPLICATION
FILL IN NAME OF YOUR ORGANIZATION IN SECTION BELOW:
ALL APPLICATIONS MUST BE TYPED AND SUBMITTED TO:
City of Pasadena
Office of the City Secretary
1149 Ellsworth Drive, 2
nd
Floor
Pasadena, Texas 77502
APPLICATION DUE: Thursday, April 2, 2020 at 4:00 pm
NO LATE APPLICATIONS WILL BE ACCEPTED
I have read and understand the application instructions prior to submitting this Application
A representative from my agency attended the Application Workshop held on March 19, 2020
I have read and signed the Terms and Conditions Section of this Application
Signature of Applicant Title Date
- I have read & executed the CONFLICT OF INTEREST DISCLOSURE FORM in this application.
- I have THOUROUGHLY reviewed the 2020 APPLICATION WORKSHOP POWERPOINT
- I have read & understand the application instructions prior to submitting this Application.
- I have read & signed the Terms and Conditions Section of this Application.
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CDBG Application
Organization Name:
Proposed Program Name:
DUNS Number:
Tax Identification Number:
Registered
with SAM.GOV
Organization’s Physical Address:
Organization’s Mailing Address:
Phone:
Fax:
Email:
Web Address:
Authorized Organization Official Signatory:
Phone:
Email:
*Primary Contact:
Phone:
Email:
* Alternate Contact:
Phone:
Email:
*Both the primary and alternate contact (provided above) will serve as intermediaries between the agency and the City of Pasadena Community
Development Department. Therefore, the primary and alternate contact shall be responsible for the distribution of information, provided by
the City of Pasadena Community Development Department, within the agency.
Type of Organization:
☐ Non Profit ☐ City Department ☐ Faith Based Organization ☐ Other: _____________________________
Category of Activity(choose one): ☐ Public Service ☐ Non-Public Service Activities
Public Service Activities (chose one):
Non-Public Service Activities (choose
one):
☐ Senior Services
☐ Disability Services
☐ Health Services
☐ Crime Prevention Services
☐ Homeless Services
☐ Youth Services
☐ Domestic Violence Victim Services
☐ Legal Services
☐ Drug Abuse Prevention Services
☐ Employment Training Services
☐ Child Care Services
☐ Other: _______________________________
☐ Public Facilities and Improvements
☐ Economic Development
☐ Other Real Property Improvements
☐ Housing Activities
☐ Micro-Enterprise Assistance
☐ Other : ___________________________________
Program Funding
1) Requested Amount of CDBG Funds
2) Other Funding Sources
3) Total Program Cost *
4) Percentage of CDBG funds toward Total Program Cost **
*Total Program Cost: (Line 1 + Line 2 = Line 3)
** Percentage of City of Pasadena funds towards program/project cost: (Line 1 ÷ Line 3 = Line 4)
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Project/ Program Delivery Description – if additional space needed use Attachment B “Scope of Work”
Provide a complete description of the proposed activity to be undertaken with federal funds including what products
or services are to be performed, where they are to be provided, for whom they are to be provided and how they are
to be provided.
Project Need – if additional space needed use Attachment B “Scope of Work”
What unmet community need(s) will your project address? How did you determine that this need(s) exists? How
will your project address this need(s)?
Project Location and Service Area
Describe the physical area to be served by the project
Include a map with the boundaries of service labeled as: Attachment A - Service Area.
*If service area is the entire City of Pasadena jurisdiction, you do not need to submit an actual map, only the
attachment labeled: Attachment A – Service Area: Entire City of Pasadena Jurisdiction
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National Objective (Chose one (1) Category and one (1) Sub-Category)
CATEGORY 1: BENEFITING LOW AND MODERATE INCOME PERSONS:
SUB-CATEGORY (please select one (1) sub-category):
Area Benefit: The activity is offered to ALL residents of an area where at least 51% of the residents are
low- to moderate income. The area must be clearly delineated and must be primarily residential.
Limited Clientele: Activity benefits a specific targeted group of persons of which at least 51% must be
LMI. In order to meet this criteria, the activity must:
Serve at least 51% LMI, as evidenced by beneficiary family size and income documentation or have
income-eligibility requirements which limit the service to persons meeting the LMI income
requirement. As evidenced by agency procedures, intake/application forms, income limits, etc.;
Serve a group primarily presumed to be LMI such as abused children, battered spouses, elderly
persons, severely disabled adults, homeless persons, illiterate adults, persons living with HIV/AIDS,
and migrant farm workers; or
Be of such a nature and in a location that it may be concluded that the activity’s clientele are LMI.
CATEGORY 2: PREVENTION OR ELIMINATATION OF SLUMS AND BLIGHT:
SUB-CATEGORY (please select one (1) sub-category):
Area Benefit: The public service is offered to ALL residents of an area where at least 51% of the residents
are low- to moderate income. The area must be clearly delineated and must be primarily residential.
Must meet ALL of the following criteria:
The area must be officially designated as a slum or blighted area by the City of Pasadena and must
meet a definition of a slum, blighted, deteriorated or deteriorating area under state or local law
The area must exhibit the following physical signs of blight or decay:
There must be a substantial number of deteriorated or deteriorating buildings throughout the area.
As a “safe harbor,” HUD will consider this test to have been met if either:
o The proportion of buildings in the area that are in such condition is at least equal to that specified
in the applicable state law for this purpose; or
o In the case where the applicable state law does not specify the percentage of deteriorated or
deteriorating buildings required to qualify the area, then at least one quarter of all the buildings
in the area must be deteriorated or deteriorating; or
o The public improvements throughout the area must be in a general state of deterioration.
Activities to be assisted with CDBG funds must be limited to those that address one or more of the
conditions which contributed to the deterioration of the area.
Spot Basis: The elimination of specific conditions of blight or deterioration on a spot basis is
designed to comply with the statutory objective for CDBG funds to be used for the prevention of blight, on
the premise that such action(s) serves to prevent the spread to adjacent properties or areas.
The activity must be designed to eliminate specific conditions of blight or physical decay not located in
a designated slum or blighted area. The activity must be limited to one of the following:
Acquisition;
Relocation;
Historic Preservation; or
Rehabilitation of buildings, but only to the extent necessary to eliminate specific conditions
detrimental to public health and safety.
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CATEGORY 3 - URGENT NEED:
Urgent Need: To comply with the national objective of meeting community development needs having a
particular urgency, an activity must be designed to alleviate existing conditions which the City certifies as
meeting one of the following criteria:
Pose a serious and immediate threat to the health or welfare of the community,
Is of recent origin or recently became urgent,
The City is unable to finance the activity on its own, and
Other resources of funding are not available to address the need.
Target Population
Please identify the primary beneficiaries this program will serve.
Project/Program Beneficiary Population (Please check only one #1 or #2)
1. Low- to moderate-income population
2. Presumed Benefit Persons (If #2 is selected you must also select a category below)
☐ Abused Children
☐ Battered Spouses
☐ Elderly Persons
☐ Persons Living with AIDS
☐ Severely Disabled Adults
☐ Migrant Farm Workers
☐ Illiterate Adults
☐ Homeless Persons
19
Performance Measures: Objectives & Outcomes
HUD requires recipients of federal funds to assess the productivity and impact of their programs/projects. Please
select one of the following objectives that best suits your proposed activity as well as one expected output that relates
to the impact that program/project is expected to have on the community or person(s) benefiting from the activity.
OBJECTIVES (choose one)
OUTCOMES (choose one)
☐ Create a Suitable Living Environment
☐ Availability/Accessibility
☐ Affordability
☐ Sustainability
☐ Provide Decent Housing
☐ Availability/Accessibility
☐ Affordability
☐ Sustainability
☐ Creating Economic Opportunities
☐ Availability/Accessibility
☐ Affordability
☐ Sustainability
OBJECTIVES – Closely mirror the statutory objectives of the program. The objectives are framed broadly to capture
the range of community impacts that occur as a result of program activities.
Creating a Suitable Living Environment – activities that are designed to benefit communities, families or
individuals by addressing issues in their living environment. This objective relates to activities that are
intended to address a wide range of issues faced by LMI persons, from physical problems with their
environment, such as poor quality infrastructure, to social issues such as crime prevention, literacy, or
elderly health services.
Providing Decent Housing - covers the wide range of housing activities that could be undertaken with CDBG
funds. This objective focuses on housing activities where the purpose is to meet individual family or
community housing needs. It does not include programs where housing is an element of a larger effort to
make community-wide improvements, since such programs would be more appropriately reported under
Suitable Living Environments.
Creating Economic Opportunities - applies to activities related to economic development, commercial
revitalization, or job creation.
OUTCOMES - helps further refine the activities objective and is designed to capture the nature of the change or the
expected result of the objective that an activity seeks to achieve. Outcomes correspond to the question “What is the
type of change the activity is seeking? Or what is the expected result of the activity?”
Availability/Accessibility - applies to activities that make services, infrastructure, public services, public
facilities, housing, or shelter available or accessible to LMI people, including persons with disabilities. In this
category, accessibility does not refer only to physical barriers, but also to making the basics of daily living
available and accessible to LMI people where they live.
Affordability applies to activities that provide affordability in a variety of ways to LMI people. It can include
the creation or maintenance of affordable housing, basic infrastructure hookups, or services such as
transportation or day care. Affordability is an appropriate objective whenever an activity is lowering the
cost, improving the quality, or increasing the affordability of a product or service to benefit a low-income
household.
Sustainability applies to activities that are aimed at improving communities or neighborhoods, helping to
make them livable or viable by providing benefit to persons of LMI or by removing or eliminating slums or
blighted areas, through multiple activities or services that sustain communities or neighborhoods.
20
Levels of Accomplishment – Goals & Performance Measures – if additional space needed use Attachment B “Scope of Work”
Total number of person’s anticipated to be assisted by project/program:
Number of unduplicated clients expected to benefit from project/program:
Description of Services Provide a description of the services that will be provided.
EXAMPLE: Program will provide counseling services to abused children
Units of Service Provide a definition of Units of Service - How will your organization determine the amount of
services rendered?
EXAMPLE: One unit of service is equal to 1 hour of counseling services
One unit of service is equal to :
Project Site Information – if additional space needed use Attachment B “Scope of Work”
Owner:
Contact Person:
Title:
Phone Number:
E-mail Address:
If agency owns property, date acquired:
If agency leases property, date the lease expires:
Employment/Client Participation
Does your organization currently notify the public that your agency does not discriminate
based on race, color, religion, gender, sexual orientation, national origin, age or disabilities
in hiring practices or provision of services?
Yes
No
If No, is your agency is willing to adopt this practice?
Yes
No
Accessibility for Physically Disabled
Will the completed project meet ADA standards for accessibility by the disabled?
Yes
No
N/A
If no, please describe accessibility problems and how you intend to correct them, including funding and
timetable:
21
Organization Capacity / Information Attachment D – Organization Information
Please check all that have been included with your application (Attachment D):
☐ Organizational Chart
☐ Articles of Incorporation
☐ Proof of Tax Exempt Status
☐ Current Year Budget
☐ List of Board of Directors
How many years has your organization been in business?
Has your organization received CDBG funding from the City of Pasadena in the past two years?
Yes
No
If yes, please provide a brief summary of the activity / amount funded:
Has your agency participated in this type of activity in the past?
Yes
No
In the space below describe your agency's past 5 years of experience with CDBG or other federal grant programs.
Include number of years working with federal grants and the type/amount of each grant received:
(list individually) – if additional space needed use Attachment B “Scope of Work”
Year Amount Type of Grant
Does your organization currently or within the last five years have any litigation that is
pending or has been resolved?
Yes
No
If yes, please attach a summary of the litigation and its status; including any outstanding judgements
Has your organization filed a petition for bankruptcy or has a petition for bankruptcy been
filed against your organization?
Yes
No
If yes, please attach an explanation that includes the current status.
What level of financial review does your organization obtain from an independent source? Select from the
following options:
☐ Single Audit
☐ Reviewed Financial Statement
☐ No Independent Review
☐ Audited Financial Statements
☐ Compiled Financial Statements
☐ Other:
Will the proposed project/program sustain if requested funds are not awarded?
Yes
No
22
Scope of Work Attachment B – Scope of Work
Describe project/program in detail. Answer ALL of the following point within description:
A. What do you intend to do and why?
B. Explain how the project/program meets the criteria of the eligible activity selected and meets the national
objective selected.
C. How does the project/program meet a community need(s)?
D. Who is your project/program beneficiary population?
E. Describe your service delivery plans including:
1) Hours of operation
2) Intake system
3) Outreach plan
F. Define how client eligibility will be determined and documented.
G. Provide a timeline for project/program execution and completion.
H. Give the program goals:
1) Units of Service (quantify the assistance and/or service program participants will receive)
2) Number of unduplicated clients you expect to serve
Do not give an overview of your agency – Be project/program specific
Must be submitted as a separate document labeled Attachment B – Scope of Work.
23
Project / Program Team
Identify the name of the responsible party, job description and the experience of each staff member that will be
involved in the administration of this activity. Personnel identified after the application are subject to review. List
only those who will be working with CDBG funds.
Staff Member
Job Description and Experience
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
24
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
Name
Title
Phone
Email
Supervisor
25
Please indicate which administrative systems you currently utilize:
Please check all that apply:
Formal personnel system with written procedures
Staff salary tracking system by funding source
Audit system incorporating formal written accounting procedures
Recordkeeping system that tracks each funding source separately
Formal written cash management practices that includes proper security measures
Hard copy files and computer records systems with security and back-up in place
Internal monitoring/evaluation system that follows written procedures
Client eligibility verification
Client demographic data collection and reporting system
Procurement policy governed by formal written procedures
Conflict of interest policies
Client grievance policies
Annual fundraising/revenue generation
26
Organization Board of Directors (City Departments - insert council members information)
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
27
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
Name
Business Affiliation
Title
Phone
Email
28
Financial Capacity & Budget Attachment E – Additional Budget Information
What is the amount of your current Annual Operating Budget?
Agency Financial System (choose one):
Cash Basis
Accrual Basis
Fiscal Year starts:
Fiscal Year Ends:
Project / Program Budget (CDBG FUNDS REQUESTED PORTION ONLY)
Please explain how each expense is related to project delivery and indicate the total cost of each line
item.
Expense
Amount
Justification
Salaries/Wages (include title and
percentage of total salary
budgeted for each position)
Fringe Benefits
Total Personnel
Supplies
Postage
Publications/Printing
Transportation
Rent
Equipment Rental
Utilities
Telephone
Other Expenses (specify)
*Purchasing equipment is NOT
allowed.
Total Non-Personnel
CDBG Funds Budget Total
29
Total Project / Program Budget (INCLUDES ALL FUNDING SOURCES)
A. Personnel
Program Funds
Total
Position Title
Annual
Salary
Annual
Fringe
Benefits
Total Annual
Salary
CDBG Requested
Amount
Additional
Funding
Source
Total
Total Personnel
B. Client Services
Program Funds
Type (i.e. Reading Materials)
Quantity
CDBG Requested
Amount
Additional
Funding
Source
Total
Total Client Services
C. Supplies
Program Funds
Type (i.e. File Folders)
Quantity
CDBG Requested
Amount
Additional
Funding
Source
Total
Total Supplies
D. Operating
Program Funds
Type (i.e. Telephone, Rent, Transportation)
Quantity
(Utilities= no.
months used)
CDBG Requested
Amount
Additional
Funding
Source
Total
Total Operating
E. Marketing Materials
Program Funds
Type (i.e. Printing Brochures)
Quantity
CDBG Requested
Amount
Additional
Funding
Source
Total
Total Marketing Costs
F. Project Costs
Program Funds
Type (i.e. Construction Support) Infrastructure Projects
please provided cost estimates by line item within
Attachment E – Additional Budget Information
Quantity
CDBG Requested
Amount
Additional
Funding
Source
Total
Total Project Costs
Grand Total (ALL funding sources)
$0.00
30
VII. SUBMISSION CHECKLIST
Item
Note
Applicant’s Initials
1.
Terms and Conditions (pgs. 2-11)
I acknowledge reading and understanding the
Terms and Conditions.
PLEASE REMEMBER:
2.
Applicants shall submit six (6) unbound copies with “ORIGINAL” signatures in a sealed envelope
or package of comparable size.
3.
Cut out and affix the Application Label to the outermost mailing envelope (UPS, USPS, FEDEX, etc.)
of your application found on page 31.
DID YOU REMEMBER TO:
4.
Fill out, sign and return the Community Development (CDBG) Submission Checklist (pg. 30)
5. Fill out, sign and return the CDBG Application (pg. 14-29)
6.
Fill out, sign and return the Conflict of Interest (pg. 32)
7.
Fill out and return the Indemnity Clause (pg. 33)
8.
Fill out and return the Non-Collusion Affidavit. Must be Notarized (pg. 34)
9.
Fill out and return Contractor’s Certification of Non-Debarment Must be Notarized (pg. 35)
10.
Fill out and return the Solicitation Questionnaire. (pg. 36)
ATTACHMENTS:
Attachment A – Service Area
Attachment B – Scope of Work
Attachment C – WWW.SAM.GOV Proof of Registration – The use of the DUNS (Data Universal Numbering
System) number has been expanded to require all applicant and grantee organizations to obtain a DUNS number and
maintain an active registration in the System for Award Management (SAM) Central Contractor Registry (CCR) database.
The website link to the System for Award Management (SAM) is WWW.SAM.GOV.
Attachment D – Organization Capacity / Information
Attachment E – Additional Budget Information
Attachment D – Proof of 501(C) Status (Nonprofit Applicants Only)
**Note: Appendix A is contingent upon the approval of the submitted application. Pursuant to the requirements of House Bill 1295, 84th
Legislative Session, any contract approved by Council is contingent upon the business entity's completion of the required Form 1295,
Certificate of Interested Parties.
I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT AND THAT IT
CONTAINS NO FALSIFICATIONS, MISREPRESENTATIONS, INTENTIONAL OMISSIONS, OR CONCEALMENT OF
MATERIAL FACTS. I FURTHER CERTIFY THAT NO CONTRACTS HAVE BEEN AWARDED, FUNDS COMMITTED,
OR CONSTRUCTION BEGUN ON THE PROPOSED PROGRAM AND THAT NONE WILL BE DONE PRIOR TO
ISSUANCE OF A RELEASE OF FUNDS BY THE CITY OF PASADENA.
SIGNATURE OF AUTHORIZED PERSON LISTED ABOVE
DATE
PRINT NAME
TITLE
31
VIII. APPLICATION SUBMISSION LABEL
LATE APPLICATIONS WILL NOT BE ACCEPTED
Please cut out and affix the application label below to the outermost mailing
envelope (UPS, USPS, FEDEX, etc.) of your submission to ensure proper delivery!
Cut along dotted line.
SEALED BID/PROPOSAL/QUALIFICATIONS
PROGRAM: Community Development Block Grant (CDBG)
DESCRIPTION: 2020 Funding Application
DUE DATE: THURSDAY, April 2, 2020
DUE TIME: NO LATER THAN 4:00 P.M. CST
ORGANIZATION NAME:
32
IX. CONFLICT OF INTEREST
All Applicants
No employee, officer, or agent shall participate in the selection, award, or administration of a contract supported by
federal funds if real or apparent conflict of interest would be involved. Such a conflict would arise when an employee,
officer, or agent, any member of his or her immediate family, his or her partner, or an organization which employs
or about to employ any of the parties indicated herein, has a financial or other interest in the firm selection for an
award.
The CDBG regulations at 24 CFR 570.611 provide that no person who is an employee, agent, consultant, officer, or
elected official or appointed official of the recipient or subrecipients that are receiving CDBG funds and (1) who
exercises or has exercised any functions or responsibilities with respect to activities assisted with CDBG funds; or
(2) who is in a position to participate in a decision-making process or gain inside information with regard to these
activities, may obtain a financial interest from a CDBG-assisted activity, or have any interest in any contract,
subcontract, or agreement with respect thereto, or the proceeds thereunder, either for themselves or those with
whom they have family or business ties, during their tenure or for one (1) year thereafter.
□ I certify that no conflict of interest exists between the City of Pasadena and ____________________________________.
Name of Subrecipient Agency
□ I certify that no conflict of interest exists between the City of Pasadena’s consultant and ____________________________________.
Name of Subrecipient Agency
□ I certify that no conflict of interest exists between the City of Pasadena and any subcontractors of
____________________________________.
Name of Subrecipient Agency
IF THERE IS A CONFLICT, COMPLETE THE FOLLOWING:
□ I certify that a conflict of interest does exist between the City of Pasadena and ____________________________________.
Name of Subrecipient Agency
□ I certify that a conflict of interest does exist between the City of Pasadena’s consultant and ____________________________________.
Name of Subrecipient Agency
□ I certify that a conflict of interest does exist between the City of Pasadena and any subcontractors of
____________________________________.
Name of Subrecipient Agency
Describe the nature of the conflict of interest below. Please identify the individual, employment, and the conflict
or potential conflict and their affiliation with your organization:
______________________________________________ ____________________
Signature Date
______________________________________________________________________________
Print Name and Title
33
X. INDEMNITY CLAUSE
THE CONTRACTOR SHALL DEFEND, INDEMNIFY AND SAVE HARMLESS
THE CITY AND ITS OFFICERS, AGENTS AND EMPLOYEES FROM
AND
AGAINST ANY AND ALL CLAIMS, DEMANDS, LIABILITIES, PENALTIES, DAMAGES, EXPENSES AND JUDGMENTS OF ANY NATURE AND
HOWEVER CAUSED, ARISING OUT OF OR RELATING TO THE
CONTRACTOR AND ITS AGENTS, SERVANTS OR
EMPLOYEES OPERATIONS IN THE CONCESSION AND CATERING SERVICES
PERFORMED BY CONTRACTOR
UNDER THIS
CONTRACT WITHIN THE CITY, INCLUDING THOSE
CLAIMS, DEMANDS, PENALTIES, DAMAGES, EXPENSES AND JUDGMENTS
WHICH
INVOLVE OR MAY INVOLVE THE ACTUAL OR ALLEGED JOINT NEGLIGENCE OF:
(i)
THE CONTRACTOR OR ANY OF ITS EMPLOYEES, AGENTS, SERVANTS OR EMPLOYEES; AND
(ii)
THE CITY, ITS OFFICERS, AGENTS, OR EMPLOYEES
IT IS THE EXPRESSED INTENTION OF BOTH THE CITY AND THE
CONTRACTOR THAT THE INDEMNITY PROVIDED FOR IN THIS
SECTION
IS INDEMNITY BY THE CONTRACTOR TO INDEMNIFY AND PROTECT THE CITY FROM THE CONSEQUENCES OF THE NEGLIGENCE
OF THE
CITY, ITS OFFICERS, AGENTS OR EMPLOYEES WHERE SUCH
NEGLIGENCE IS A CONCURRING CAUSE OF INJURY, LOSS,
DEATH OR
DAMAGE. FURTHERMORE, IT IS THE EXPRESSED INTENTION OF BOTH
THE CITY AND THE CONTRACTOR THAT THE
INDEMNITY PROVIDED
FOR IN THIS SECTION SHALL HAVE NO APPLICATION TO ANY CLAIMS,
LOSS, DAMAGE, CAUSE OF ACTION, SUIT
OR LIABILITY WHERE THE
INJURY, DEATH OR DAMAGE RESULTS FROM THE NEGLIGENCE OF THE CITY UNMIXED WITH THE FAULT
OF THE CONTRACTOR OR ANY OF ITS EMPLOYEES. FOR PURPOSES OF THIS INDEMNIFICATION PROVISION, ACTS AND/OR OMISSION OF
THE CONTRACTOR'S OFFICERS, AGENTS,
SERVANTS, AND EMPLOYEES SHALL BE CONSIDERED THE ACTS AND
OMISSIONS OF THE
CONTRACTOR.
Company/ Name of Agency
Mailing Address (PO Box or street)
City, State, and Zip Code
Name of Authorized Representative
Signature Title
Telephone # Fax #
34
XI. NON-COLLUSION AFFIDAVIT (MUST BE NOTARIZED)
State of (State)
County of (County) §.
Being first duly sworn, deposes and says that:
He/She is the (Owner, Partner, Officer, Representative or Agent) of
(Company), the party that has submitted the attached
Proposal;
He/she is fully informed respecting the preparation and contents of the attached Proposal and of all pertinent
circumstances respecting such Proposal;
Such application is genuine and is not a collusive or sham application;
Neither the said applicant nor any of its officers, partners, owners, agents, representatives, employees or parties in
interest, including this affiant, have in any way colluded, conspired, connived or agreed, directly or indirectly, with
any other Proposer, firm, or person to submit a collusive or sham Proposal in connection with the Work for which
the attached Proposal has been submitted; or to refrain from bidding in connection with such Work; or have in any
manner, directly or indirectly, sought by agreement or collusion, or communication, or conference with any
Proposer, firm, or person to fix the price or prices in the attached Proposal or of any other Proposer, or to fix any
overhead, profit, or cost elements of the Proposal price or the Proposal price of any other Proposer, or to secure
through any collusion, conspiracy, connivance, or unlawful agreement any advantage against (Recipient), or any
person interested in the proposed Work;
The price or prices quoted in the attached Proposal are fair and proper and are not tainted by any collusion,
conspiracy, connivance, or unlawful agreement on the part of the Proposer or any other of its agents, representatives,
owners, employees or parties in interest, including this affiant.
Authorized Representative’s Signature Company Name
Representative’s Name Representative’s Title
On this the _____ day of _______ , 20 , before me, the undersigned Notary Public of the State of Texas,
personally appeared the individual whose name is subscribed to within the instrument, and he/she/they
acknowledge that he/she/they executed it.
WITNESS my hand and official seal.
NOTARY PUBLIC
SEAL OF OFFICE: ______________________________________________________
(Name of Notary Public: Print, Stamp, or Type as Commissioned)
35
XII. CERTIFICATE OF NON-DEBARMENT (MUST BE NOTARIZED)
DATE:
NAME/ADDRESS OF APPLICANT ENTITY:
APPLICANT NAME:
CITY OF PASADENA
COMMUNITY DEVELOPMENT DEPARTMENT
P.O. BOX 672
PASADENA, TX 77501-0672
2020 funding application for CDBG
(I) (We) certify that no individual, firm, partnership or association which is hereby bidding on the above-named project
is designated as not being debarred from contracting on federally-funded projects or as an ineligible contractor by the
Controller General of the United States pursuant to Section 5.6(b) of the Regulations of the Secretary of Labor, Part 5
(29 CFR, Part 5) or pursuant to Section 3(a) of the Davis-Bacon Act, as amended (10 U.S.C. 276u-2(a).
LEGAL NAME AND BUSINESS ADDRESS OF THE APPLICANT:
THE APPLICANT IS:
A SINGLE PROPRIETORSHIP
A CORPORATION ORGANIZED IN THE STATE OF:
A PARTNERSHIP
OTHER ORGANIZATION (DESCRIBE):
APPLICANT’S FEDERAL ID (DUNS) NUMBER:
____ - _______ - _______
NAME, TITLE AND ADDRESS OF THE OWNER, PARTNERS OR OFFICERS OF THE APPLICANT:
NAME
TITLE
ADDRESS
Name of Applicant:
Authorized Representative Signature:
Name and Title:
STATE OF TEXAS §
COUNTY OF HARRIS §
BEFORE ME, the undersigned authority, on this day personally appeared ___________________________, know to me to be
the person and officer whose name is subscribed to the foregoing instrument, and acknowledged to me that he executed the
same for the purposes and consideration herein expressed and in the capacity therein stated as the act and deed of said
_______________________________.
GIVE UNDER MY HAND AND SEAL OF OFFICE this the ________day of ____________________, A.D., 20_______.
NOTARY PUBLIC AND FOR THE STATE OF TEXAS
Name: __________________________________________
WARNING
U.S. Criminal Code, Section 1010, Title18, U.S.C., provides in part: “Whoever, Makes, passes, utters, or published any statement, knowing the same
to be false …. Shall be fined not more than $5,000 or Imprisoned not more than two years, or both.”
36
XIII. SOLICITATION QUESTIONNAIRE
The City of Pasadena constantly strives to improve competitive bidding. In order to facilitate these improvements,
we would like to know how you were informed that this application and how you may have received a copy of the
document.
How did you learn of this funding opportunity?
Direct Contact with Community Development Department
City of Pasadena Website www.pasadenatx.gov
Newspaper or trade publication
Chamber of Commerce
Other Means: Describe
How did you obtain your copy of the application document?
Direct Contact with Community Development Department
Via Email Via Fax In Person
City of Pasadena Website www.pasadenatx.gov
Notification service
Other Means: Describe
37
Example: Certificate of Interested Parties
Pursuant to the requirements of House Bill 1295, 84th Legislative Session, any contract approved by Council is contingent
upon the business entity's completion of the required Form 1295, Certificate of Interested Parties.
Revised 11/30/2015
Form provided by Texas Ethics Commission www.ethics.state.tx.us
FORM CIQ
OFFICE USE ONLY
This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session.
This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who
has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the
vendor meets requirements under Section 176.006(a).
By law this questionnaire must be filed with the records administrator of the local governmental entity not later
than the 7th business day after the date the vendor becomes aware of facts that require the statement to be
filed. See Section 176.006(a-1), Local Government Code.
A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An
offense under this section is a misdemeanor.
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
Date Received
A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income,
other than investment income, from the vendor?
Yes No
B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction
of the local government officer or a family member of the officer AND the taxable income is not received from the
local governmental entity?
Yes No
7
Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts
as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1).
Signature of vendor doing business with the governmental entity
Date
Name of vendor who has a business relationship with local governmental entity.
1
Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated
completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which
you became aware that the originally filed questionnaire was incomplete or inaccurate.)
2
3
Name of local government officer about whom the information is being disclosed.
Name of Officer
Describe each employment or other business relationship with the local government officer, or a family member of the
officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer.
Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form
CIQ as necessary.
4
6
5
Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or
other business entity with respect to which the local government officer serves as an officer or director, or holds an
ownership interest of one percent or more.
Revised 11/30/2015
Form provided by Texas Ethics Commission www.ethics.state.tx.us
CONFLICT OF INTEREST QUESTIONNAIRE
For vendor doing business with local governmental entity
A complete copy of Chapter 176 of the Local Government Code may be found at http://www.statutes.legis.state.tx.us/
Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form.
Local Government Code § 176.001(1-a): "Business relationship" means a connection between two or more parties
based on commercial activity of one of the parties. The term does not include a connection based on:
(A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an
agency of a federal, state, or local governmental entity;
(B) a transaction conducted at a price and subject to terms available to the public; or
(C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and
that is subject to regular examination by, and reporting to, that agency.
Local Government Code § 176.003(a)(2)(A) and (B):
(a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if:
***
(2) the vendor:
(A) has an employment or other business relationship with the local government officer or a
family member of the officer that results in the officer or family member receiving taxable
income, other than investment income, that exceeds $2,500 during the 12-month period
preceding the date that the officer becomes aware that
(i) a contract between the local governmental entity and vendor has been executed;
or
(ii) the local governmental entity is considering entering into a contract with the
vendor;
(B) has given to the local government officer or a family member of the officer one or more gifts
that have an aggregate value of more than $100 in the 12-month period preceding the date the
officer becomes aware that:
(i) a contract between the local governmental entity and vendor has been executed; or
(ii) the local governmental entity is considering entering into a contract with the vendor.
Local Government Code § 176.006(a) and (a-1)
(a) A vendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship
with a local governmental entity and:
(1) has an employment or other business relationship with a local government officer of that local
governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A);
(2) has given a local government officer of that local governmental entity, or a family member of the
officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any
gift described by Section 176.003(a-1); or
(3) has a family relationship with a local government officer of that local governmental entity.
(a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator
not later than the seventh business day after the later of:
(1) the date that the vendor:
(A) begins discussions or negotiations to enter into a contract with the local governmental
entity; or
(B) submits to the local governmental entity an application, response to a request for proposals
or bids, correspondence, or another writing related to a potential contract with the local
governmental entity; or
(2) the date the vendor becomes aware:
(A) of an employment or other business relationship with a local government officer, or a
family member of the officer, described by Subsection (a);
(B) that the vendor has given one or more gifts described by Subsection (a); or
(C) of a family relationship with a local government officer.
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CITY OF PASADENA COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG) (City of Pasadena, Texas)

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Completed 25 February 2021

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